Addiction
What is addiction?
Addiction is a complex condition, a brain disease that is manifested by compulsive substance use despite harmful consequence.
45 yo man w/ CC of fatigue. B/c of drinking he has received several reprimands at work, and wife has threatened to leave him. Drinks 6-12 beers daily and several ounces of hard liquor. He reports blackouts, inability to quit, tolerance for alcohol, and withdrawal Sx. He has tried to quit but has been unable. Diagnosis? (don't overthink this one..)
Alcohol Dependence
3 or more of the following present:
() Tolerance for alcohol
() Withdrawal sx (elevated vital signs, tremors, delirium tremens, seizures)
() alcohol taken in larger amount than was intended
() Much time spent obtaining alcohol, using alcohol, or recovering from the effects of alcohol
() Important activities given up because of alcohol use
() Alcohol use continued despite the knowledge that it worsens physical or psychological problems.
54 yo M with long-standing hx of substance abuse presents to the ED with abdominal pain, sweats, diarrhea and body aches. On initial evaluation pt noted to have watery nose and eyes, fever of 37.8C, and dilated pupils. Mood dysphoric. What is the diagnosis?
Opioid Withdrawal
SLUD- Salivation, Lacrimation, Urination, and Defecation.
Sensitivity to touch and light, goose flesh, autonomic hyperactivity, gastrointestinal distress, joint and muscle aches, yawning, salivation, lacrimation, urination, diarrhea, and a depressed or anxious mood.
Uncomfortable but NOT life-threatening unless complicated by severe preexisting physical condition.
Behavioral Tx of alcohol abuse?
Alcoholic Anonymous sponsored 12-Step program.
(Address denial that one has an addiction, feelings of responsibility and blame, discouraging behavior of loved ones, establishing social support system, and hope within a community.)
Withdrawal seizures, delirium tremens, Wernicke Korsakoff syndrome, cerebellar degeneration, peripheral neuropathy, fetal alcohol syndrome, hepatic encephalopathy, malabsorption syndromes, pancreatitis, cardiomyopathy, macrocytic anemia, and increased incidence of trauma are all complications of what substance?
Alcohol Dependence
What is an important distinction between substance abuse and substance dependence?
Substance Abuse: using drug, meds, or alcohol in any other way than it should be used.
Substance Dependence: needing more to feel the same thing as before. Body gets used to it and now needs more.
Which factor is most specific for alcohol dependence?
A. Driving while intoxicated.
B. Marital Conflicts
C. Not becoming intoxicated as easily
D. Occupational Problems
E. 12-y Hx of reg. alcohol use
C. Tolerance for alcohol (experiencing either the same effect with an increased amount or a decreased effect with the same amount), withdrawal from alcohol, and inability to control alcohol use are characteristics of alcohol dependence.
25 yo M brought into ED by girlfriend for nosebleed. Pt has hx of nose bleeds amenable with pressure. Pt is very anxious and agitated. BP 160/102, HR 114 Pupil size 6 mm b/l. What is likely explanation?
Cocaine use
Cocaine use causes tachycardia, hypertension, agitation, mydriasis, which are all present in this patient
Medication to aid in abstinence from alcohol?
Antabuse (disulfiram) medication that blocks the enzyme acetaldehyde dehydrogenase.
Causes extremely uncomfortable Sx. Pt needs to be motivated, responsible, and without significant cognitive deficits, to ensure compliance.
Bonus: ReVia (naltrexone) decreases craving for alcohol, blocks the rewarding effects.
Pt has triad of delirium, ataxia, and opthalmoplegia. Diagnosis?
Wernicke encephalopathy
What does the CAGE mnemonic stand for?
Have you ever felt you should Cut down?
Have you ever felt Annoyed/angry by someone criticizing your alcohol use?
Have you ever felt Guilty about your drinking?
Have you ever had an Eye opener (eg. drink 1st thing in the morning)
Screens for alcohol dependence.
Two "yes" responses indicate that the possibility of alcoholism should be investigated further.
State in which body adapts to a drug, requiring more of it to achieve a certain effect?
Tolerance
Patient with apathy, psychomotor retardation, constricted pupils, and drowsiness. Dx?
Opiate intoxication
Tx of acute intoxication of person "found down" suspected of alcohol abuse?
IVF, monitoring, coma cocktail: naloxone (reverse possible opiates), thiamine (pt low in thiamine), D50 (reverse hypoglycemia)
D50 AFTER thiamine to avoid exacerbation of cell death. D50 won't do anything w/o thiamine
60-yo man brought to ER by wife for "confusion". He is a heavy drinker and drinks a case daily x 30 years. He as been eating less over the past year, preferring alcohol to large meals. Last drink was this morning. What is a likely finding of his MSE?
A. Confabulation
B. Delusions
C. Elevated affect
D. Fluctuating consciousness
E. Loose Associations
A. Confabulation
Chronic thiamine deficiency results in Korsakoff syndrome, characterized by anterograde amnesia. The missing memories are often filled in with false information.
Difference between Addiction and Pseudoaddiction?
Addiction: harmful compulsive desire to obtain drugs to create a feel-good effect.
Pseudoaddiction: Seeks out more pain medication for self-care. Caused by under prescription of drugs to treat pain in the patient.
Observe over time once a pseudoaddict finally gets adequate pain management, drug-seeking subsides.
State in which drug-specific physical or mental symptoms are elicited when drug use is abruptly ceased.
Withdrawal
Withdrawal from _______ includes a "crash," including hypersomnia, hyperphagia, and depressed mood and a sensation of bugs crawling on skin.
Cocaine Withdrawal
25 yo in ED w/ chest pain, he hasn't slept in 24 hrs and has been taking pills to study longer for national dental board exam. He is diaphoretic, extremely agitated. Temp 38.9C, HR 115, BP 160/102. Pupils 7mm b/l. Lungs CTA. Suspected stimulant intoxication. Initial Tx? (name a class of drug)
Benzodiazepines (lorazepam)
Pt. w/ stimulant intoxication (amphetamine/cocaine overdose) treated with benzo to sedate pt, control HTN, and prevent seizures.
Febrile pts cooled externally.
Hospitalized homeless pt hospital day 2 with constant nausea, frequent dry heaves and vomiting, severe tremors of the arms even when not extended, pt is severely drenched in sweat, severely anxious appears to be in a panic attack, patient is pacing about the room in agitation, is experiencing both auditory and visual hallucinations, with a pounding 10/10 fullness in his head, he is also disoriented to place. What is the total CIWA-Ar Score (mdcalc.com)? What is needed to prevent severe effects from alcohol withdrawal?
Clinical Institute Withdrawal Assessment for Alcohol CIWA
67
Patients with scores ≥20 frequently require medication for withdrawal, and may also require admission to the ICU for observation for seizures or development of delirium tremens, and more frequent medication dosing.